Resident Working Hours and Outcome Measures
We remain confused and uncertain about resident working hours and the relationship with patient outcome and doctors’ training and wellbeing. The underlying hypothesis is that long working hours lead to fatigue and that this increases the likelihood of medical error. The counter argument is that shorter periods of clinical exposure reduce the quality and quantity of medical training particularly in craft specialties. It is an argument about ‘flying hours’ and how many are needed in order to be suitably competent. The other aspect of the discussion is the issue of ‘life work balance’ and how the current trainee juggles his professional duties and personal commitments. This debate has been heightened by the increased feminization of the medical workforce. The recent series of work stoppages by doctors in the UK has centered round issues such as the expense of childcare when individuals are working unsocial hours at weekends.
The US, against a background of a long working hours system, have analysed these issues in considerable detail. In 2003 the Accreditation Council for Graduate Medical Education (ACGME) reduced resident duty periods to 80 hours per week, capped overnight shift lengths, and regulated minimum time off between shifts. In 2011, the ACGME brought in further restrictions. These consisted of shorter shift lengths for interns, and greater time off for residents after overnight on-call duty.
The underlying question is what impact these changes over the last 13 years have had on patient care and doctor wellbeing. The aspirations have been that the curtailed hours would reduce fatigue-related clinical errors. That physician health, and safety would be improved. On the other hand the concerns expressed were that the lesser training hours would reduce valuable clinical exposure, and that patient continuity would be adversely affected.
In a large study of surgical services, Bilimora et al1 have addressed these issues in the FIRST trial. The study design was a comparison between standard duty-hour policies and flexible less-restrictive duty-hour policies for surgical trainees. There were 117 general surgery residency programs across the US enrolled in the study. It involved 139,000 patients and 4330 residents. In the flexible less-restrictive limb, the trainees were granted waived rules on maximum shift lengths and time off between shifts. The total time worked was the same in both groups, 80 hours per week. The rate of death or serious complications was 9% in both limbs of the study. The residents’ satisfaction with the overall education quality was also similar between the 2 groups. The residents in the flexible less-restrictive duty-hour policy group were less likely to be dissatisfied with the continuity of care and the quality of handoffs, but more dissatisfied with the time for rest. In addition, they were less likely to leave or miss an operation.
In summary the less-restrictive duty-hours policies did not have any significant adverse effects on patient outcomes or on residents satisfaction with well-being or education quality.
However, the residents found that the less-restrictive hours had a negative effect on time spent with family and friends, and extracurricular activities.
The findings in Bilimoria’s study suggest that duty-hour reforms have not improved patient safety. A possible explanation is the practice of work compression, where residents process clinical tasks more quickly and less thoroughly in order that they are completed within the restricted timeframe. Continuity of care and decision-making could be adversely affected, particularly with ill patients whose condition is rapidly changing. In this scenario a decision regarding a key surgical or medical intervention may be incorrectly deferred and ‘left for’ the next resident on duty to sort out. Such delays can be critical for the patient’s outcome. Patients do better when an individual, identifiable doctor worries about the patient and for the patient. The hand-overs are a potential pitfall. Nurses have a formal, detailed hand-over process but with doctors it tends to be more informal and less detailed. This is the legacy of an era when long working hours meant that the doctor was very familiar with all the patients. This no longer the case, and doctors just like their nursing counterparts need high quality handover arrangements.
Birkmeyer2 in an editorial interprets the results differently. He points out that it is not surprising that the patient outcomes did not differ between the 2 groups. In the current era residents have far less autonomy and mostly operate and function clinically with close senior supervision. Also intensive care units are increasingly ‘closed’ facilities run almost exclusively by intensivists. He states that although few surgical residents would openly admit it they would be happy to hear ‘we can take care of this without you, go home, go home see your family and come back fresh tomorrow’.
Despite the equivocal findings from Bilimoria’s study, the reduced hours for trainee doctors are here to stay, but flexibility appears to be beneficial. Nobody should have to work excessively long hours, it simply unfair and unnecessary. It remains widely accepted that sleep deprivation adversely affects performance and increases the likelihood of an error. Nobody accepts the excuse “well we did it when we were in training’.
In this country we are currently readjusting to the shorter NCHD hours. Many observers have commented that trainees now take longer acquire clinical and procedural skills. Consultant out-of-hours acute care involvement has increased and is certain to continue. The pragmatic changes to NCHD training need to be addressed. One of the ways that trainees can compensate for their shorter training hours is to work in high volume, high patient turnover hospitals. The combination of shorter hours and low case volume does not provide residents with sufficient clinical experience. Secondly, the consultant staff numbers need to increase substantially commensurate with their current greater provision of clinical care. Over time the health care system needs to be become less dependent on trainees and more consultant provided. This can only be brought about by a substantial change in the consultant-trainee ratio.
1. Bilimoria KY, Chung JW, Hedges LV et al. National cluster-randomised trial of duty-hour flexibility in surgical training. N Engl J Med 2016;374:713-727
2. Birkmeyer JD. Surgical resident duty-hour rules- weighing the new evidence. N Engl J Med 2016;783-784